Helen Bernardy Center D/P SNF

Inspectors wroteBased on observation, interview and record review, the facility did not honor a resident's responsible party's preference for showers for one of 13 residents (Res 1). As a result, Resident 1 did not receive showers in over two years as requested by the responsible party.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a resident's privacy and dignity were protected during personal care for one of 13 residents (Res 4). This had the potential to cause embarrassment for Res 4 by being exposed during personal care. According to the Resident admission Record, Resident 4 (Res 4) was admitted to the facility on [DATE], with diagnosis that included cerebral palsy (a group of permanent disorders that affect movement, muscle tone, and posture, caused by abnormal brain development or brain injury) and repeated Urinary Tract Infections (UTI- common bacterial infection). Res 4 does not speak, and is dependent on staff for all Activities of Daily Living (ADL's-movement, eating, oral hygiene, dressing, transfer, change of position, and bathing). Res 4 cannot control bladder and bowels, and is changed by staff. On 3/8/26 at 1:32 P.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and maintain infection control practices when a tube feeding syringe for 1 of 13 sampled residents (22) was found hanging on the tube feeding pole and not in its plastic bag. This failure had the potential to spread bacteria to Resident 22. Per the facility admission record, Resident 22 was admitted to the facility on [DATE] with diagnoses that included gastrostomy status (placement of a plastic tube into the stomach to administer medications, nutrition and fluids). On 3/8/26 at 1:00 P.M., an observation of Resident 22's room was conducted. An inspection of Resident 22's tube feeding equipment was done and a tube feeding syringe (device used to administer medications, fluids and nutrition) was found hung on the pole and not in the plastic bag. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate services were consistently implemented for four of four sampled residents (Resident 1, 2, 3, and 4) when: 1) care plans were not followed 2) the Interdisciplinary Team (IDT) recommendation was not followed 3) care plan was not updated/revised As a result, there was a potential for the residents ' overall care and health to be negatively impacted.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food safety and sanitation practices were met in the kitchen according to standards of practice when: 1. Two (2) floor sinks had piping without an air gap of at least 1 (inch) between the pipe and drain. 2. Three (3) cutting boards with deep cuts and food stains were stored in the clean area. 3. Two (2) ice machines had debris inside the storage parts of the ice bin. 4. Food thermometers were not calibrated per facility policy. These failures exposed residents to unsanitary practices, which had the potential to place them at risk of developing foodborne illness. 1. During the initial kitchen tour conducted on 11/19/24 at 8:44 A.M., a floor sink drain next to the salad prep/catering area was observed with the PVC (polyvinyl chloride) white pipe extending into the floor drain. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - health status screening and assessment tool) was accurately completed for 1 of 6 sampled residents (Resident 3). This failure had the potential for Resident 3 to receive inappropriate care.

Inspectors wroteBased on interview and record review, the facility failed to revise a comprehensive care plan for intermittent and indwelling catheterization (a procedure where a tube is inserted to remove urine from the bladder) for one of six sampled residents (Resident 3). This failure had the potential for Resident 3 to have negative clinical outcomes.

Inspectors wroteBased on interview and record review, the facility failed to upload the Minimum Data Set (MDS) for three of three residents (59, 63, 66) within an appropriate time frame. This failure had the potential of not having the residents not receiving the appropriate care.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection control practices when a licensed nurse did not perform hand hygiene after administering medications via gastrostomy tube (GT- a tube inserted directly into the stomach used to provide nutrition and medication) and before doing tracheostomy (a surgical opening created through the neck to help someone breathe) site care to one of five residents observed for medication pass. As a result, there was the potential for cross contamination of microorganisms (bacteria, virus, fungus).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. All controlled medications/drugs (medications/drugs with a potential for addiction and abuse) were stored separately in locked, permanently affixed compartments for storage of controlled drugs when three out of six medication carts had controlled medications stored among the non-controlled medications. 2. A medication cart located inside the medication room, containing controlled medications, was locked. As a result of this deficient practice, a controlled medication was unaccounted for. In addition, there was the potential for drug diversion (unauthorized distribution of controlled drugs for purposes not intended by the prescriber).

Inspectors wroteBased on observation, interview and record review, the facility failed to post the federally required daily actual hours worked by the staff in an area accessible to the public when the information was not posted until the last shift for the day clocked in. As a result, the actual hours worked by the staff was not readily accessible to residents, family, or visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. All controlled drugs (medications/drugs with a potential for addiction and abuse) were reconcilled and accounted for. 2. Licensed Nurse (LN) 4 safeguarded a resident's medications during the medication administration when the LN left the resident's dispensed medications unattended in the hallway. As a result of these deficient practices, the facility could not provide an accurate accounting of all controlled medications and there was a potential for controlled drug diversion (unauthorized distribution of controlled drugs for purposes not intended by the prescriber). In addition, unattended medication had the potential to be tampered with and not administered as intended.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of 12 sampled residents (Resident 4) was free from unnecessary psychotropic medications (medications affecting mood, thoughts, and behavior) when the resident had been prescribed Trazodone (a medication used to treat major depressive disorder, a serious mood disorder affecting how a person thinks and feels) for sleep which was a non-FDA approved indication for use. This deficient practice had the potential to cause the resident harm.